Thierry Yzet

Is there a place for pigtail drains in the management of gastric leaks after laparoscopic sleeve gastrectomy

Laparoscopic sleeve gastrectomy (LSG) has a specific morbidity profile in which gastric leak (GL) is the main complication. With a view to defining a standardized protocol for GL management, the present retrospective study sought to describe the clinical patterns of post-LSG GL and treatment of the latter in our university medical center. From July 2004 to December 2010, 25 patients were included. GL was described in terms of clinical presentation, time to onset, and location in the staple line. Treatment of GL with pharmacologic, radiologic, endoscopic, and/or surgical procedures was always validated by a multidisciplinary care team. “Treatment success” was defined as the absence of contrast agent leakage on CT and endoscopy after removal of covered metallic stent or pigtail drains. Systemic inflammation and peritonitis were the main signs for early-onset GL (56%), whereas pulmonary symptoms and intra-abdominal abscesses revealed delayed-onset GL (44%). Surgery was always performed for early-onset GL. In the total study population, the median number of endoscopic procedures was five (range, 1–11) per patient, of covered SEMS was three (range, 1–8), and of pigtail drains was three (range, 1–4). Nine (36%) patients presented endoscopic-related complications. Four (16%) patients with treatment failure underwent radical surgery. The mortality rate was 4% (n=1). The management of post-LSG GL is challenging. Surgery was always performed for early-onset GL, whereas treatment of delayed-onset GL was based on endoscopy. Pigtail drains required fewer procedures per patient, were better tolerated, and had lower morbidity–mortality than covered SEMS.

Case Report—Complex Management of a Postoperative Bronchogastric Fistula After Laparoscopic Sleeve Gastrectomy

Laparoscopic sleeve gastrectomy (LSG) is a new restrictive bariatric procedure increasingly indicated in the treatment of morbid obesity. Postoperative complications are mainly represented by gastric fistula with an occurrence rate of 0% to 5.1% in the literature. This complication is difficult to manage and requires multiple radiological, endoscopic, and surgical procedures. We report herein the case of a 23-year-old woman who underwent LSG for morbid obesity. This patient was reoperated for peritonitis due to a gastric fistula located on the top of the staple line. Five months later, she complained of a cough with fever and expectoration. A methylene blue test and a computed tomography scan diagnosed a postoperative bronchogastric fistula. After failure of aggressive conservative management, radical surgery was performed with total gastrectomy, reconstruction of the diaphragm using the extended latissimus dorsi flap, and a pulmonary lobectomy. This case report highlights the possible issue of the complex management of gastric fistula after LSG.

Hepatic vascular flow measurements by phase contrast MRI and doppler echography: A comparative and reproducibility study

To directly compare and study the variability of parameters related to hepatic blood flow measurements using 3 T phase‐contrast magnetic resonance imaging (PC‐MRI) and Doppler ultrasound (US).

Acute cholecystitis: preoperative CT can help the surgeon consider conversion from laparoscopic to open cholecystectomy.

PURPOSE To establish whether preoperative computed tomographic (CT) findings in patients with acute cholecystitis were associated with conversion from laparoscopic to open cholecystectomy in patients with calculous acute cholecystitis. MATERIALS AND METHODS The study protocol was approved by the local institutional review board, and written informed consent was provided by all patients at enrollment. From 2008 to 2010, all patients admitted to a university medical center with acute calculous cholecystitis and for whom a preoperative contrast material-enhanced CT study was available were prospectively included. Cholecystectomy was always initiated laparoscopically. To identify risk factors for conversion specifically related to acute cholecystitis, CT studies were analyzed according to predefined criteria by two radiologists who were blinded to the patients conversion status. Associations between conversion and radiologic findings were assessed by using univariate and multivariate logistic models. RESULTS A total of 108 patients were analyzed (61 men, 47 women; median age, 58 years; age range, 17-88 years). Conversion occurred in 24 (22%) cases. On preoperative CT images, the absence of gallbladder wall enhancement was associated with the presence of gangrenous acute cholecystitis (sensitivity, 73%). The absence of gallbladder wall enhancement (58% and 40% for conversion and nonconversion, respectively; P = .02) and the presence of a gallstone in the gallbladder infundibulum (78% and 22% for conversion and nonconversion, respectively; P = .04) were associated with acute cholecystitis-related conversion in a multivariate analysis. Interobserver agreement for CT study interpretation was very good (median k value, 0.92; range, 0.76-1.00). CONCLUSION The absence of gallbladder wall enhancement (associated with the presence of gangrenous acute cholecystitis) and the presence of a gallstone in the gallbladder infundibulum are associated with conversion from laparoscopic to open cholecystectomy.

Endoscopic treatment of chronic pancreatitis.

OBJECTIVES Endoscopy offers an alternative to surgery for the treatment of ductal complications in patients with chronic pancreatitis. The aim of this study was to evaluate the efficacy of endoscopic treatment on pain, cholestasis and pseudocysts in these patients. PATIENTS AND METHODS Thirty-nine patients (37 M, 2 F, mean age 44), were included in the study. All patients had at least one of the following criteria demonstrated by imaging tests: dilatation of the main pancreatic duct (MPD) with or without stricture (N = 13), bile duct stricture (N = 12), or pancreatic pseudocyst (N = 14) with pancreatic duct stricture (N = 11) or biliary stricture (N = 3). Pancreatic or biliary sphincterotomy, insertion of pancreatic or biliary stent, pseudocyst drainage with stent placement were performed according to ductal abnormalities. Patients were evaluated early and followed up during the stenting period, and after stent removal. RESULTS Patients underwent a median of 3.5 endoscopic procedures with an interval of 2.2 months between 2 stenting sessions. A pancreatic or biliary stent was inserted in 25 patients with ductal abnormalities and in 11 patients with pseudocysts. Endoscopic pseudocyst drainage was performed in 6 cases. The mean stenting time was 6 months (range: 3-21). Mean follow-up after stent removal was 9.7 (2-48) months. Complications of endoscopic treatment were encountered in 7% of patients with no deaths. Pain relief was achieved after the first endoscopic procedure and during the overall stenting period in all patients. Recurrence of pain was observed after stent removal in 5/11 patients, requiring surgery in 4. Cholestasis decreased and biochemical values normalized within one month after biliary stenting. Recurrence of cholestasis was observed early after stent removal in 4/9 patients who required complementary surgical treatment. No recurrence of pancreatic pseudocyst was observed after endoscopic drainage and stent removal during the follow-up period. CONCLUSIONS Endoscopic treatment of pain from pancreatic pseudocysts or ductal strictures is effective in the short-term and in the period of ductal stenting. However, the optimal duration of the latter remains to be determined.

Biliary drainage, photodynamic therapy and chemotherapy for unresectable cholangiocarcinoma with jaundice

Background and Aim:  The combination of photodynamic therapy and biliary stenting seems to be beneficial in the palliative treatment of unresectable cholangiocarcinoma. We aimed to assess the accuracy of photodynamic therapy in a single centre.

Management of gastrobronchial fistula after laparoscopic sleeve gastrectomy

BACKGROUND Gastric fistula (GF) is a serious complication after laparoscopic sleeve gastrectomy (LSG). Furthermore, gastrobronchial fistula (GBF) may appear some time after a primary LSG. The objective of this study was to characterize GBF after LSG and establish standardized treatment procedures. METHODS All patients undergoing surgery for GBF after LSG at a public university medical center in France between November 2004 and January 2013 were included in this study. Surgical and perioperative care was standardized. The primary efficacy criterion was the complication rate. Secondary efficacy criteria were the mortality rate, surgical data, types of complications, and the length of stay (LOS) in hospital. RESULTS Six patients were treated for GBF after LSG: 2 presented GBF after primary LSG performed in our institution and 4 had been referred by tertiary centers. The median (range) time to onset of GBF after LSG was 136 days (99-238 d). Preoperative refeeding was performed in 5 cases. The median time interval between the discovery of GBF and its surgical treatment was 31 days (7-137 d). Five patients underwent simultaneous abdominal and thoracic procedures. The abdominal procedures consisted of total gastrectomy (n = 1) and 60-cm Roux-en-Y gastrojejunal anastomosis (n = 6). There were no postoperative mortalities. Four postoperative complications occurred (66.6%), 2 of which were postoperative fistulas (33.3%) requiring revisional surgery. The median time to oral refeeding was 10 days (8-65 d) and the median LOS was 14 days (13-25 d). CONCLUSIONS Our treatment of GBF is based on effective drainage with endoscopic procedures, allowing optimal preoperative refeeding before combined abdominal and thoracic surgery. For the abdominal procedure, we prefer a 60-cm Roux-en-Y gastrojejunal anastomosis to total gastrectomy, because the former is simpler and minimizes the long-term risk of postoperative malabsorption.

Persistent gastric fistula after sleeve gastrectomy: an analysis of the time between discovery and reoperation

BACKGROUND Gastric leak (GL) represents one of the main early-onset postoperative complication of sleeve gastrectomy (SG). Most studies of GL featured short series and no data on the time to reoperation for persistent GL. OBJECTIVES Characterize the time between discovery of persistent post-SG GL and the implementation of reoperation. SETTING University hospital, France, public practice. METHODS All patients treated for post-SG GL between November 2004 and December 2013 were included. The primary efficacy criterion was the time interval between discovery of a persistent GL and reoperation. The secondary efficacy criteria were demographic, surgical, and endoscopic data; mortality rate; time to GL healing; treatment success rate; and risk factors for failure treatment. RESULTS Eighty-six patients were treated for post-SG GL. Forty patients (46.5%) had early-onset GL (postoperative day ≤ 7). Two patients (2.3%) presented primary gastrobronchial fistula. Fifty-six patients (70%) underwent immediate reoperation. Endoscopic treatment was required to treat the GL in 92.7% of the cases (n = 77). The mortality rate was 1.2% (n = 1). The treatment success rate was 89.1%. The median time to healing GL was 84 days (14-423 d). Eighty percent of the GLs had healed 120 days after discovery. After 120 days, the incidence of complications related to GL increased and few additional GLs healed. The only identified risk factor for treatment failure was large retained gastric fundus (P ≤ .05). CONCLUSIONS Most cases of GL can be adequately treated by incorporating endoscopic stenting. Surgery for persistent GL should be performed within 120 days of discovery; after this cut-off, the incidence of GL-related complications increases. Large retained gastric fundus is a risk factor for treatment failure and may prompt the surgeon to consider earlier reoperation.

Three-dimensional computed tomography analysis of the left gastric vein in a pancreatectomy

BACKGROUND During a pancreatectomy, the left gastric vein (LGV) has an important role in the venous drainage of the stomach (total pancreatectomy, left splenopancreatectomy, pancreatoduodenectomy with venous resection and pylorus-preserving pancreaticoduodenectomy). Pre-operative knowledge of the LGVs termination is necessary for adequate protection of this vein during dissection. The objective of the present study was to analyse the location of the LGVs termination in a patient population and facilitate its identification in at-risk situations. MATERIALS AND METHODS Abdominal computed tomography (CT) images of 86 pancreatic tumour patients (20 of whom underwent surgery), who were treated in our institution between October 2009 and October 2010, were reviewed. Arterial-phase and portal-phase helical CT with three-dimensional reconstruction was performed in all cases. The location of the termination of the LGV was determined and (when the LGV merged with the splenic vein or the splenomesenteric trunk) the distance between the termination and the origin of the portal vein (PV). The correlation between CT imaging data and intra-operative findings was studied. RESULTS The LGV was identified on all CT images. In 65% of cases (n= 56), the LGV terminated in the PV (upstream of the liver in nine of these cases). The LGV terminated at the splenomesenteric trunk in 4.7% of cases (n= 4) and in the splenic vein in 30.3% of cases (n= 26). When the LGV terminated upstream of the origin of the PV, the distance between the two was always greater than 1 cm. The average distance between the termination of the LGV and the origin of the PV was 14.34 mm (10.2 to 21.1). The anatomical data from CT images agreed with the intra-operative findings in all cases. CONCLUSION Pre-operative analysis of the LGV is useful because the vein can be identified in all cases. Knowledge of the terminations anatomic location enables the subsequent resection to be initiated in a low-risk area.

Feasibility of the Glissonian approach during right hepatectomy

OBJECTIVE The Glissonian approach during hepatectomy is a selective vascular clamping procedure associated with low rates of technical failure and complications. The aim of the present study was to assess the feasibility of a right Glissonian approach in relation to portal vein anatomy. METHODS This was a prospective study conducted over a 12-month period, which included 32 patients for whom preoperative three-dimensional reconstruction using contrast-enhanced computed tomography in the portal venous phase and portography for right portal vein embolization were available, and in whom a right Glissonian approach was applied during right hepatectomy. Preoperative imaging data were correlated with intraoperative Doppler ultrasound findings (considered as the reference dataset). Causes of failures and complications specifically related to the Glissonian approach were identified. RESULTS Right hepatectomy was performed for colorectal liver metastases (n = 25), hepatocellular carcinoma on cirrhosis (n = 6) and intrahepatic cholangiocarcinoma (n = 1). The Glissonian approach was effective in 24 (75%) patients. In the remaining eight (25%) patients, failure was caused by incomplete clamping (n = 2) or clamping of the left portal pedicle (n = 6). The portal anatomy was aberrant in six patients with failure, showing portal trifurcation (n = 1), right portal trifurcation (n = 1) and a common trunk between the right anterior and left portal branch (n = 4). An angle of less than 50° between the portal vein and left portal branch was reported in association with extended clamping to the left portal branch (selectivity = 72%, specificity = 71%). Intraoperative bleeding and biliary fistula occurred in two patients with non-normal portal anatomy. CONCLUSIONS The right Glissonian approach was effective in 75% of patients. Failure of the procedure (including the extension of clamping to the left pedicle) mostly occurred in patients with portal vein variations, which can be accurately assessed using a combination of preoperative imaging and intraoperative Doppler ultrasound.